Provider Demographics
NPI:1871948695
Name:GARRETT, KYLE
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:
Last Name:GARRETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2704 W TERRACE DR
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-3622
Mailing Address - Country:US
Mailing Address - Phone:478-718-1684
Mailing Address - Fax:
Practice Address - Street 1:2704 W TERRACE DR
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-3622
Practice Address - Country:US
Practice Address - Phone:478-718-1684
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANOT YET ISSUED1223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics